Urine Tricarboxylic Acid Cycle Metabolites Predict Progressive Chronic Kidney Disease in Type 2 Diabetes

CONTEXT

Metabolites in the tricarboxylic acid (TCA) cycle are not only involved in energy metabolism but also play important roles in non-energy production activities.

OBJECTIVE

To study whether baseline urine key TCA cycle metabolites (lactate, pyruvate, citrate, α-ketoglutaric acid, succinate, fumarate, and malate) independently predict risk of chronic kidney disease (CKD) progression [fast estimated glomerular filtration rate (eGFR) decline] in individuals with type 2 diabetes mellitus (T2DM).

DESIGN

One discovery and one validation nested case-control studies in two independent T2DM cohorts.

SETTING AND PARTICIPANTS

Subjects with T2DM were recruited and followed in a regional hospital and at a primary care facility.

MAIN OUTCOME MEASURES

eGFR trajectory (slope) was estimated by linear regression. Progressive CKD was defined as eGFR decline of ≥5 mL/min/1.73 m2 per year.

RESULTS

As compared with those with stable renal function (n = 271), participants who experienced progressive CKD (n = 116) had a lower level of urine citrate but significantly higher levels of lactate, fumarate, and malate levels at baseline. Both fumarate and malate predicted progressive CKD independent of traditional cardio-renal risk factors, including eGFR and albuminuria. Fumarate interacted with sex (P for interaction = 0.03) and independently predicted progressive CKD in male but not female participants. All these findings were reproducible in a validation study (case n = 96, control n = 402). Exploratory analysis suggested that fumarate might partially mediate the effect of oxidative stress on CKD progression.

CONCLUSIONS

Key TCA cycle metabolites, especially fumarate, may be involved in the pathophysiologic pathway independent of traditional cardio-renal risk factors, leading to CKD progression in patients with T2DM.

[Identification of metabolites of Danshensu in vivo in rats]

To identify the metabolites of Danshensu in plasma and urine in rats by using UHPLC-LTQ-Orbitrap method. After oral gavage of Danshensu CMC-Na suspension in SD rats, urine and plasma samples were collected and processed by solid phase extraction. ACQUITY UPLC BEH C₁₈ column (2.1 mm×100 mm, 1.7 μm) was utilized, with 0.1% formic acid (A)-acetonitrile (B) solution as the mobile phase for gradient elution. Negative electrospray ion mode based data-acquisition method was established to collect the mass spectrometry data of biological samples. As a result, Danshensu and 21 Danshensu Ⅰ phase and Ⅱ phase metabolites were finally identified according to the accurate mass measurements, mass fragmentation behaviors and comparing with the reference standards. The main metabolic pathways included dehydration, methylation, glucuronide conjugation, sulfate conjugation and their composite reactions. Consequently, our study expounded metabolites of Danshensu in rats based on UHPLC-LTQ-Orbitrap method and provided a reference for further researches on therapeutic material basis and mechanism of Danshensu.

Urinary VMA, dopamine and the likelihood of neuroblastoma: a preferred way of reporting laboratory results?

Background: Neuroblastoma patients may be classified as normal or abnormal depending on reference interval and decision points for urine catecholamine metabolites. We therefore evaluated the utility of positive likelihood ratios (LR+) based on data from patients in whom the diagnosis was suspected.

Methods: Urine samples from 249 patients (122 male, 127 female) suspected of neuroblastoma were assayed for VMA by spectrophotometry and dopamine by HPLC. Ratios of VMA to creatinine (VMA/Cr) and dopamine to creatinine (DA/Cr) were calculated and age-related median scores derived relative to patients without neuroblastoma. Receiver operator characteristic (ROC) curve analysis was undertaken for the ability of median scores to identify neuroblastoma.

Results: Of the 249 patients, there were 20 confirmed cases of neuroblastoma, with ages ranging from 0 (congenital tumour) to 8.4 years. From ROC curves, VMA/Cr was found to have an area under the curve 0.96 (95% confidence interval [CI] 0.92-0.98) compared with 0.72 (95% CI 0.66-0.77) for DA/Cr, P=0.001. At the optimal decision point for VMA/Cr, LR+ was 7.2, identifying cases with a sensitivity of 95% and a specificity of 86%, and comparing favourably with published intervals.

Conclusions: VMA/Cr is more accurate than DA/Cr for the diagnosis of neuroblastoma. Reporting LR+ may also be more informative than using reference intervals and decision points.

Renal excretion of pyruvate, lactate and alpha-ketoglutarate in kidney donors before and after nephrectomy and in patients with terminal uremia

The excretional patterns of lactate, pyruvate and alpha-ketoglutarate have been investigated in 7 patients with terminal uremia and in 10 kidney donors with normal renal function before and after unilateral nephrectomy. Methods for analysis of the three substances in urine were elaborated. In all patients, the levels of renal excretion of lactate and pyruvate were very low, and clearance values were independent of the glomerular filtration rate (GFR). alpha-ketoglutarate clearance varied to some extent with renal function, but no correlation to GFR was found, and exceeded the GFR in uremic patients, indicating that the net result of renal handling of alpha-ketoglutarate may be a tubular secretion.

The excretional patterns of lactate, pyruvate and alpha-ketoglutarate in renal transplants

The excretional patterns of lactate, pyruvate and alpha-ketoglutarate were investigated after renal transplantation in 36 patients. Fourteen patients had received a living-donor kidney with short ischemia time and good initial graft function, 22 had a cadaver transplant with an initial 125iothalamate clearance of more than 6 ml/min. The excretion of lactate and pyruvate did not vary significantly from that seen in normal controls or patients with uremia. In six patients with cadaver transplants, clearance values of alpha-ketoglutarate exceeded that of the glomerular filtration rate, indicating a net tubular secretion of this substance. During acute rejection episodes in 5 patients, no changes were seen in the excretional patterns of lactate, pyruvate and alpha-ketoglutarate.

3,4-methylenedioxymethamphetamine (MDMA) intoxication in an infant chronically exposed to cocaine

Accidental ingestion of 3,4-methylenedioxymethamphetamine (MDMA, ecstasy) was detected in an infant admitted at the Pediatric Emergency Department by drug testing in urine. Concentrations of MDMA and its principal metabolite 4-hydroxy-3-methoxymethamphetamine (HMMA) in the infant's hydrolyzed urine were 11.7 mg/L and 34.4 mg/L, respectively. Apparent febrile convulsions and cardiovascular side effects resolved within 1 day after treatment with benzodiazepines. Chronic exposure to cocaine was evidenced by segmental hair analysis. Continuous maternal denial of the presence of any drug in the household made diagnosis of accidental ingestion of MDMA and chronic exposure to cocaine problematic. Periodic clinical and laboratory follow-ups were requested to check eventual long-term effects of exposure to illicit drugs and discontinuation of the child from exposure to dangerous environments.

[Determination of danshensu in urine and its pharmacokinetics in human]

AIM

To determine Danshensu in urine and study its pharmacokinetics in human.

METHODS

A solid phase extraction-HPLC method was used for determination of Danshensu in urine of human. HPLC separation is performed on a Shim-pack CLC-ODS column (150 mm x 6.0 mm ID, 5 microns) with a mobile phase composed of acetonitrile -0.01 mol.L-1 KH2PO4 (adjusted to pH 2.8 with phosphoric acid). The flow rate was 1.0 mL.min-1 and the UV detector was set at 280 nm. The linear range of Danshensu was 0.2-50 mg.L-1 (r = 0.9999), and its limit of detection was 1.5 ng. The mean recovery was 99.4% (RSD = 2.9%).

RESULTS

The pharmacokinetics of Danshensu after p.o. administration of two kinds of pharmaceutical preparations containing Danshen (with 20 mg of Danshensu) were investigated in 6 healthy human volunteers by determining the Danshensu in urine samples. The elimination half lives (T1/2) of Danshensu after p.o. administration of compound granule preparation A and decoction of Danshen were (0.92 +/- 0.16) h and (0.94 +/- 0.21) h, respectively. Their excretions of Danshensu in urine were (6.2 +/- 2.8)% and (14 +/- 4)% of the dose in 8 hours, respectively.

CONCLUSION

Under normal doses, Danshensu can be eliminated from kidney. There is no evident difference on elimination half lives of Danshensu after p.o. administration of the two doses, but the excretions of Danshensu by urine after p.o. administration of compound granule preparation A were lower than that of decoction of Danshen.

Capillary electrophoresis for the determination of organic acidurias in body fluids: a review

A systematic review of the literature on capillary electrophoresis applied to short chain organic acid analysis in body fluids has been conducted with special interest on those acids related to inborn errors of metabolism. The technique is briefly described, as well as the choice of the main analytical parameters: sample pre-treatment, polarity, capillary type, background electrolyte, and detection. The applications described in the literature are listed and the main features of the technique are discussed.

Control of propranolol intake by direct chromatographic detection of alpha-naphthoxylactic acid in urine

A rapid chromatographic procedure with a C18 column, a mobile phase of 0.15 M sodium dodecyl sulfate (SDS)-10% (v/v) 1-propanol at pH 3 (0.01 M phosphate buffer), and fluorimetric detection, is reported for the control of propranolol (PPL) intake in urine samples, which are injected directly without any other treatment than filtration. The peak of PPL was only observed in samples taken a few hours after ingestion of the drug due to its extensive conjugation and metabolisation. The detection of several unconjugated PPL metabolites was therefore considered: desisopropylpropranolol (DIP), propranolol glycol (PPG), alpha-naphthoxylactic acid (NLT) and alpha-naphthoxyacetic acid (NAC). NLT showed the best characteristics: it eluted at a much shorter retention time than PPL, its concentration in urine samples was greater and it did not present any interference from endogeneous compounds in urine, common drugs or drugs administered in combination with PPL. The limit of quantification, measured as the concentration of analyte providing a relative standard deviation of 20%, was 24 ng/ml, and the day-to-day imprecision was below 4% for concentrations above 200 ng/ml. The procedure allows the routine control of PPL at therapeutic urine levels. Urinary excretion studies showed that the detection of NLT is possible at least up to 20-30 h after oral administration.

Direct determination of 1-naphthoxylactic acid in biological fluids by non-protected fluid room temperature phosphorimetry

A selective and sensitive room-temperature phosphorimetric method for the direct determination of 1-naphthoxylactic acid (NA) in biological fluids is described. It is based on obtaining a phosphorescence signal from NA using TlNO3 as a heavy atom perturber and Na2SO3 as a deoxygenator without a protective medium. This technique is named non-protected room-temperature phosphorescence (NP-RTP), which allows to determine analytes in complex matrices without the need for tedious prior separation. Optimization of the operational conditions resulted in a detection limit for NA of 9.6 ng/mL according to the error propagation theory. The repeatability and standard deviation were also determined. This method was successfully applied to the determination of NA in urine and human serum.

Catecholamine secretion and ploidy in phaeochromocytoma

The aim was to evaluate 24 hr urine catecholamine, HMMA and HVA excretion in relation to ploidy in phaeochromocytoma. Data from five diploid and nine tetraploid tumours showed a significant reduction in urine noradrenaline (p = 0.02) and HMMA (p = 0.03) in diploid tumours but no difference in adrenaline, dopamine and HVA excretion using the Mann-Whitney U test. None of the patients showed recurrence after a mean of 5.7 years of follow up. A review of published ploidy studies in phaeochromocytoma shows that malignancy is more than six times more common in non-diploid tumours but diploidy does not equate with benignity. No biochemical marker is a reliable index of malignancy. All patients should undergo lifetime review for recurrence.

D-lactic acidosis 23 years after jejuno-ileal bypass

Accumulation of D-lactate after gastrointestinal surgery, particularly jejuno-ileal bypass, is an uncommon and often misdiagnosed clinical disturbance. The syndrome may be complicated by dizziness, ataxia, confusion, headache, memory loss, and aggressive behavior. Serum chemistries are often deceptive because the anion gap is frequently normal in spite of severe metabolic acidosis. Moreover, the urine anion gap may be positive, incorrectly suggesting a defect in renal net acid excretion. Indeed, the combination of a normal anion gap metabolic acidosis and positive urine anion gap may erroneously suggest a diagnosis of renal tubular acidosis. Importantly, all reported cases of D-lactic acidosis secondary to bypass surgery have been encountered within 5 to 10 years following the surgery. Here we present an unusual case of D-lactic acidosis (complicated by encephalopathy) presenting 23 years after a jejuno-ileal bypass procedure. The patient was initially diagnosed with a drug intoxication secondary to benzodiazepines. Ultimately, the diagnosis of D-lactate encephalopathy was established after challenging the patient with a carbohydrate load. Thus, administration of 40 kcal/kg over 16 hours reproduced the clinical syndrome and was accompanied by a marked increment in serum and urine D-lactate concentration. The patient had sustained resolution of her symptoms after treatment with oral vancomycin.

NaHCO(3) and KHCO(3) ingestion rapidly increases renal electrolyte excretion in humans

This paper describes and quantifies acute responses of the kidneys in correcting plasma volume, acid-base, and ion disturbances resulting from NaHCO(3) and KHCO(3) ingestion. Renal excretion of ions and water was studied in five men after ingestion of 3.57 mmol/kg body mass of sodium bicarbonate (NaHCO(3)) and, in a separate trial, potassium bicarbonate (KHCO(3)). Subjects had a Foley catheter inserted into the bladder and indwelling catheters placed into an antecubital vein and a brachial artery. Blood and urine were sampled in the 30-min period before, the 60-min period during, and the 210-min period after ingestion of the solutions. NaHCO(3) ingestion resulted in a rapid, transient diuresis and natriuresis. Cumulative urine output was 44 +/- 11% of ingested volume, resulting in a 555 +/- 119 ml increase in total body water at the end of the experiment. The cumulative increase (above basal levels) in renal Na(+) excretion accounted for 24 +/- 2% of ingested Na(+). In the KHCO(3) trial, arterial plasma K(+) concentration rapidly increased from 4.25 +/- 0.10 to a peak of 7.17 +/- 0.13 meq/l 140 min after the beginning of ingestion. This increase resulted in a pronounced, transient diuresis, with cumulative urine output at 270 min similar to the volume ingested, natriuresis, and a pronounced kaliuresis that was maintained until the end of the experiment. Cumulative (above basal) renal K(+) excretion at 270 min accounted for 26 +/- 5% of ingested K(+). The kidneys were important in mediating rapid corrections of substantial portions of the fluid and electrolyte disturbances resulting from ingestion of KHCO(3) and NaHCO(3) solutions.

Analysis of orotic acid in human urine by on-line combination of capillary isotachophoresis and zone electrophoresis

The techniques of the on-line combination of capillary isotachophoresis with zone electrophoresis in two coupled capillaries (ITP-CZE) and a single capillary zone electrophoresis (CZE) were used for the sensitive determination of orotic acid (OA) in human urine. The simple CZE system was successfully applied for fast and reliable analyses of urine of healthy adult volunteers (the detection limit 1.7.10(-6) M OA, the total time of analysis 6 min). However, this method failed in analyses of OA in urine of ill children due to more complex matrix of the samples. Here, the ITP preconcentration and preseparation step coupled on-line with CZE proved to serve well with an electrolyte system developed and optimized for this purpose. The maximum selectivity and resolution of OA from other sample constituents in ITP-CZE was achieved by use of an electrolyte system of very low pH 2.15 both for ITP and CZE stage. The sensitivity of detection and simplicity of OA identification were enhanced by use of an external UV scanning detector. High sensitivity of ITP-CZE combination (limit of detection 3.10(-7) M OA), low sample consumption (1 microliter), good reproducibility of migration times (inter-day RSD < 1.86%) and acceptable reproducibility of the determination of OA in urine samples (average RSD = 7.27%) make this technique suitable for routine determination of trace concentration of OA especially in urine of ill children under various pathological conditions and medication.

[Analysis of MDMA and its metabolites in urine by GC and GC/MS]

The purpose of this study is to investigate the metabolism of MDMA in the person and establish the methods for the determination of MDMA and its metabolites in urine. MDMA and its metabolite were isolated from urine by liquid-liquid extraction after acidic or enzymatic hydrolysis and were determined by GC/MS(EI, PCI) and GC/FID. The results showed that MDMA was metabolized to MDA and HMMA in man. MDA in the urine after MDMA administration was approximately 0.10-0.14 that of the parent drug. The sensitivity limits of methods were 2-50 ng/ml, and the recoveries were greater than 85%(CV < 10%). It is concluded that the methods were simple, quick and accurate for determining urine concentration of MDMA addicts. MDA/MDMA Ratio can be used to indicate whether the parent drug is taken alone or in combination with its active metabolite.

Successful treatment by direct hemoperfusion of coma possibly resulting from mitochondrial dysfunction in acute valproate intoxication

PURPOSE

We evaluated the efficacy of direct hemoperfusion (DHP) for treatment of acute valproate (VPA) intoxication and speculate on the biochemical perturbations that suggest a mechanism of coma induced by VPA overdose.

PATIENT AND METHODS

The comatose patient was hospitalized approximately 6 h after ingesting 18 g VPA. DHP, with 200 g activated charcoal, was performed for 6 h. The plasma concentrations of VPA and Glasgow coma scale scores after admission were estimated. Before and after DHP, urine samples were tested in serial fashion for VPA metabolites, organic acids, and acyl carnitine esters of fatty acids.

RESULTS

Plasma VPA was efficiently adsorbed on activated charcoal. The patient's plasma concentration of VPA decreased from 471 microg/ml (2,830 microM) to 45 microg/ml (270 microM), at which point the patient became alert. The half-life (t1/2) of VPA was calculated as 4.4 h before DHP and as 1.8 h during DHP. Before DHP, lactate and VPA-glucuronide markedly increased in urine samples, but beta-keto-VPA, a major mitochondrial metabolite, was not detected. Urinary excretion of carnitine esters of medium chain (C8-C10) dicarboxylic acids was increased. After DHP, lactate and VPA-glucuronide decreased, but a significant amount of beta-keto-VPA was demonstrated. Carnitine esters of medium chain dicarboxylic acids were decreased.

CONCLUSIONS

DHP with activated charcoal was effective treatment for the patient with acute VPA intoxication and coma. The onset of coma may have been related to inhibition of beta-oxidation in the mitochondria, which was reversible by elimination of plasma VPA by DHP.

Comparison of urinary component levels in 4 strains of mice with different physiological characteristics

Changes in urinary component levels before, during and after reproduction were examined with 1H-nuclear magnetic resonance (NMR) in four strains of female mice with different mammary tumour potential and related characteristics (SHN, SLN, GR/A and C3H/He). Regardless of the variations in these changes among the strains, the urinary component levels reflected physiological changes during reproduction and some strain-specific characteristics. The urinary excretion of citrate, 2-oxoglutarate and lactate increased from the virginal stage to pregnancy and declined during lactation in all strains, indicating a marked change in sugar metabolism during reproduction. SHN and SLN, which are from the same basal stock, showed a similar pattern and the level, of several components were lower than those of GR/A and C3H/He. The levels of some lower components were compensated for by higher urine excretion. The levels of taurine and betaine, both essential for fetal and pup growth, increased at lactation in only GR/A, reflecting the poorer pup growth observed in this strain. Finally, the 1H-NMR method was useful to estimate not only the metabolic but also the physiological changes of the animals without invasion, pain or distress and would thus contribute to animal welfare in the animal experiments.

Phaeochromocytoma--a rare cause of hypertension in an 11-year-old girl

Severe sustained hypertension occurs in only 0.1% of the paediatric population and only about 2% of these patients will have an underlying endocrine cause. Phaeochromocytoma as a catecholamine-secreting tumour causing severe hypertension is exceedingly rare in children. A high index of suspicion and an awareness of the clinical spectrum are therefore necessary to make the diagnosis. Phaeochromocytomas can have protean manifestations which may be mistaken for a variety of clinical conditions. We highlight the problems encountered in making the diagnosis in an 11-year-old Chinese girl who presented with sustained hypertension, heart failure and transient renal impairment with two normal 24-hour urinary vanillyl mandelic acid (VMA) results before a third produced the diagnosis. We emphasize that total reliance on a single biochemical urinary screening is not acceptable. The measurement of urinary catecholamines or their metabolites increases the sensitivity of diagnosis. We recommend that in situations where biochemical screening is doubtful, appropriate imaging should be undertaken to exclude the diagnosis.

False-positive postmortem EMIT drugs-of-abuse assay due to lactate dehydrogenase and lactate in urine

Three cases of multiple false-positive drug tests are described. Postmortem urine specimens were screened using the enzyme-multiplied immunoassay technique. All patients had proteinuria and lactic aciduria. These false-positive reactions were due to the presence of lactate dehydrogenase (LDH), lactic acid, and protein. This finding was confirmed by creating a multiple false-positive sample with a solution of LDH and lactate in 5% bovine serum albumin at pH 6.

A study of the nephrotoxicity of three cephalosporins in rabbits using 1H NMR spectroscopy

Male New Zealand White rabbits received a single intravenous injection of 125 mg/kg cephaloridine, 500 mg/kg cefoperazone or 1000 mg/kg cephalothin. Histological examination of kidneys at 48 h post-dose confirmed the presence of bilateral necrosis of the proximal convoluted tubules in the cephaloridine-treated animals. 1H-NMR urinalysis of cephaloridine-treated rabbits detected drug-related resonances, decreased hippurate and increased glucose at 0-24 h post-dose accompanied by elevated levels of lactate, glycine, citrate, glutamine/glutamate and alanine at 24-48 h post-dose. No histopathological changes were observed following administration of cefoperazone or cephalothin. 1H-NMR spectra of urine collected from these animals showed drug-related resonances and decreased hippurate levels at 0-24 h post-dose, and increased glucose levels at 24-48 h post-dose. Analysis of urine by conventional clinical-chemistry failed to reveal any statistically significant differences between the treatment groups. Under the conditions of this study, the nephrotoxic effects of cephaloridine and the minimal effects of cefoperazone and cephalothin could be clearly distinguished by 1H-NMR urinalysis but not by conventional urinalysis.

High-resolution proton nuclear magnetic resonance studies of urine from asphyxiated newborn infants

High-resolution proton nuclear magnetic resonance spectroscopy was used to study human urine obtained from 10 normal babies and twenty babies with various degrees of neonatal asphyxia, respiratory distress syndrome (RDS), and meconium aspiration syndrome (MAS). All sick babies showed different degrees of oxygen deficiency, indicated by an obvious increase of the lactate signal level in the urine spectra. Changes in the concentration of other urinary metabolites produced from the citric acid cycle were also observed. In extremely serious cases, the signals of some of the major components, including citrate, alpha-ketoglutarate, and succinate, simply disappeared. The spectra of urine, serum, and CSF of an infant suffering from SIDS showed common characteristics of the metabolites.

Lack of uniformity in the clinical approach to the interpretation of urinary catecholamines and their metabolites

A study of the case notes from 101 of the 113 instances where at least one of the results was abnormal from the analysis of 24 hr urinary collections for noradrenaline, adrenaline, and dopamine and their metabolites 4-hydroxy-3-methoxy-mandelic acid (HMMA) and homovanillic acid (HVA) in screening for phaeochromocytomas in hospitals affiliated to the Royal College of Surgeons in Ireland Medical School from a total of 199 false positives from all sources shows that 51% had a second sample, 33% had ultra sound, 12% had a CT scan, 6% had an 131I metaiodobenzylguanadine (MIBG) scan, 40% had no imaging performed and in 5% the reports were not received by the referring medical team. The 12 sets of data where case notes could not be retrieved were disregarded. Of the 22 patients with one or more biochemical value greater than twice the upper reference range, 8 had not, by our criteria had a phaeochromocytoma positively excluded. The sensitivity and specificity for phaeochromocytoma diagnosis for the free catecholamines together was 82% and 88.4%; for HMMA 60% and 95.8%; and for catecholamines and HMMA together 82% and 93.2% respectively. A protocol which includes repeat samples where results are abnormal and the appropriate use of diagnostic imaging should be systematically pursued to minimise false negative diagnoses.

Phaeochromocytoma--a laboratory experience

Thirteen phaeochromocytomas were found over five and a half years from 2,834 patient requests for tumour screens. HMMA (VMA) was the usual screening test requested. Free catecholamines were reported when specifically requested by clinicians and where the HMMA level was > 40 mumol/24 hr. HMMA and urinary free catecholamines were estimated using HPLC with electrochemical detection in acidified 24 hr collections. Noradrenaline was elevated in all thirteen, nine had raised adrenaline and two had raised levels of all three catecholamines. Urinary free catecholamines are the most appropriate analyte package in our circumstances for the diagnosis of phaeochromocytoma. HMMA if used alone could lead to false negative diagnoses but it has a role in minimising false negatives where urinary catecholamine results are normal.

Acid-base balance in chronic peritoneal dialysis patients

Endogenous acid production has never been measured directly in dialysis patients and an empiric formula is used to estimate acid production from their protein catabolic rate. We have studied acid-base balance in 19 stable CAPD patients attending the peritoneal dialysis clinic of Mount Sinai Hospital. They obtained a 24 hour collection of peritoneal dialysis fluid and urine while consuming their usual diet and performing their usual activities. Total alkali gain was calculated from net GI alkali absorption plus urinary net acid excretion plus alkali gain from dialysate, while total acid production was measured directly from the urinary and dialysate excretions of sulfate and organic anions. Net GI alkali absorption was estimated from the difference between cations (Na + K+Ca + Mg) and anions (Cl + 1.8P) in the 24 hour dialysate and urine collections minus the daily total amount of lactate infused. All of our patients had a normal or high serum bicarbonate concentration, which was stable with time. Total alkali gain was virtually identical to total acid production (54.2 vs. 52.4 mEq/day) which suggests that these patients were in neutral acid-base balance. Net GI alkali absorption (22.7 mEq/day) was one of the same range as that of chronic renal failure patients not on dialysis and represented almost one half of the total daily alkali gain. The daily acid production of 52.4 mEq/day was numerically equal to 84% of the protein catabolic rate expressed as g/day, which is similar to the predicted value of 77% of PCR reported in the literature.(ABSTRACT TRUNCATED AT 250 WORDS)

D-lactic acidemia and aciduria in pediatric and adult patients with short bowel syndrome

D-Lactate produced by abundant intestinal lactobacilli during acidotic episodes in short bowel (SB) patients is commonly regarded as a main factor in the pathogenesis of SB syndrome-associated (D-lactic) acidosis. Since we had observed that gram-positive bacteria, mainly lactobacilli, were abundant even in the absence of acidosis, we studied serum concentrations and urinary excretions of D- and L-lactate in young and adult SB patients, especially during nonacidotic periods. Serum L-lactate and urinary L-lactate excretion were similar in adults and children. Serum D-lactate and urinary D-lactate excretion were higher in SB children than in SB adults. Food consumption affects D-lactate production and alters D-lactic acidemia and aciduria. We conclude that D-lactate is frequently present in serum of SB patients even in the absence of acidosis. High serum concentrations and urinary excretions may reflect dietary factors in these patients.

Renal function during chronic anemia in the ovine fetus

Our purpose was to determine how prolonged anemia alters fetal renal function and acid-base balance. In seven ovine fetuses made progressively anemic over 1 wk by serial isovolemic hemorrhage, hematocrit was reduced from 33.3 +/- 4.5 to 14.0 +/- 1.0%. Femoral arterial oxygen content was less and renal plasma flow was greater in anemic fetuses (1.5 +/- 0.1 ml/dl and 339 +/- 58 ml.min-1.100 g kidney-1) than in 6 control fetuses (7.0 +/- 1.3 ml/dl and 160 +/- 34 ml.min-1.100 g kidney-1). Urine flow and sodium excretion were also greater in anemic fetuses (1.2 +/- 0.6 ml/min and 79 +/- 49.5 mumol/min) than in controls (0.5 +/- 0.2 ml/min and 16 +/- 9.8 mumol/min). This higher sodium excretion was apparently due to a lower fractional sodium reabsorption in anemic fetuses compared with controls (84.1 +/- 5.8 vs. 96.5 +/- 1.7%), rather than to differences in either glomerular filtration rate or amount of filtered sodium. In addition, the higher sodium excretion in anemic fetuses was associated with greater urinary lactate and inorganic phosphate excretions and larger amniotic fluid volumes than in controls. From these data we conclude that when fetal renal oxygen delivery is limited by a prolonged reduction in hematocrit, excretions of sodium and water, as well as other osmotically active solutes, increase, and this results in an increase in amniotic fluid volume.

Jamaican vomiting sickness in Toledo, Ohio

The endemic illness of Jamaica known as ackee poisoning is reported for the first time in the United States. The toxic exposure resulted from the consumption of canned ackee. The epidemiology, diagnosis, theoretical mechanism, and possible therapy of this disease are discussed.

Effects of inhibition of prostaglandin synthesis on flow and composition of fetal urine, lung liquid, and swallowed fluid in sheep

OBJECTIVE

Our aim was to determine the effects of blocking prostaglandin synthesis, by infusion of indomethacin into the fetal circulation, on factors regulating amniotic fluid volume and on plasma composition in the mother and fetus.

STUDY DESIGN

Indomethacin was administered to fetal sheep during 8 hours at 124.0 +/- 1.2 days of gestation (n = 7) and at 134.7 +/- 0.8 days of gestation (n = 7) (term approximately 147 days). Vehicle infusions were performed at 128.8 +/- 1.4 days of gestation (n = 5).

RESULTS

Fetal urine production was significantly reduced and both fetal urine osmolality and plasma arginine vasopressin concentrations were significantly elevated in response to indomethacin infusions at both gestational ages. Fetal blood and urine lactate concentrations were elevated in response to indomethacin. Later in gestation, fetal lung liquid flow was significantly changed from a net efflux to a net influx. There was no significant effect of indomethacin on the volume of fluid swallowed by the fetus.

CONCLUSION

Inhibition of fetal prostaglandin synthesis profoundly reduces the production of the two major fetal fluids contributing to amniotic fluid, namely, urine and lung liquid. These findings may explain why indomethacin reduces amniotic fluid volume.

Oestrogen and progesterone receptors in mammary tumours of male SHN mice grafted with pituitaries in comparison with females

Mammary tumour induced by pituitary grafting in SHN male mice is promising as an animal model for male breast cancer. In this study, these mice (group MC) were found to differ little from the intact female SHN (group FC) in cytosolic oestrogen receptor (OR) level in either normal or neoplastic mammary glands. On the other hand, Progesterone receptor (PR) level in normal glands tended to be lower in group MC than in group FC, which was recovered by chronic treatment with oestradiol benzoate (group OB). Little difference in PR level in mammary tumours was seen between groups MC and FC. Mammary tumorigenesis was significantly inhibited by chronic treatment with dihydrotestosterone to male mice with pituitary grafts (group DHT). This is associated with the significant decline in PR level in normal mammary glands, while not in mammary tumours. There were no significant correlations between OR and PR levels in normal or neoplastic mammary glands, or between normal and neoplastic mammary glands in OR or PR in all groups except group MC, in which the correlation between OR and PR in mammary tumour was significant. All findings indicate that OR and PR states in mammary tumours of male mice induced by pituitary grafting are essentially similar to the spontaneous mammary tumours of females as postulated in the human.

Pitfalls in aminoacid and organic acid analysis: 3-hydroxypropionic aciduria

Pitfalls in organic acid analysis can originate from inadequate methodology, analytical interferences, in vivo interactions and from pre-analytical conditions which often are unknown to the specialized analytical laboratory. Among the latter, ingested food and additives, metabolites of food processing or medications have to be considered. Bacterial metabolites from the gastrointestinal or urogenital system or formed after sample collection can lead to pitfalls as well. An example of such a patient whose urinary metabolites mimic at first glance inherited propionic aciduria is described.

Metabolic pathways of 1-butyl [3-13C]acrylate. Identification of urinary metabolites in rat using nuclear magnetic resonance and mass spectroscopy

1-Butylacrylate, an industrial monomer, is rapidly metabolized by carboxylesterase-catalyzed hydrolysis to acrylic acid and 1-butanol. Acrylic acid enters the intermediary metabolism and is efficiently degraded to carbon dioxide as the metabolic end product. To obtain a virtually complete metabolic pattern, rats were dosed by a single intraperitoneal dose of 1 mmol/kg 1-butyl [3-13C]acrylate. The urine was then analyzed by a one-dimensional 1H-detected and two-dimensional 1H-13C shift-correlated heteronuclear multiple-quantum NMR experiment. In this experiment, three urinary metabolites, namely, 3-hydroxypropanoic acid, N-acetyl-S-(2-carboxyethyl)cysteine, and N-acetyl-S-(2-carboxyethyl)cysteine sulfoxide, were identified comparing their 1H and 13C chemical shifts with those of authentic standards. In another experiment, to enhance minor metabolic pathways, rats were dosed with 0.25 mmol/kg of a carboxylesterase inhibitor, tri-o-tolyl phosphate, prior to 0.5 mmol/kg butyl [3-13C]acrylate. Under these conditions, N-acetyl-S-(2-carboxyethyl)cysteine, N-acetyl-S-[2-(butoxycarbonyl)-ethyl]cysteine, and N-acetyl-S-(2-carboxyethyl)cysteine sulfoxide were found in urine. No metabolites which would arise from a possible metabolic activation of 1-butyl acrylate to 1-butyl oxiranecarboxylate and its subsequent hydrolysis or glutathione conjugation were found. It is estimated that any metabolite amounting to more than 1% of the dose should be detected under these conditions. To study the routes by which BA enters the intermediary metabolism, incorporation of the label into urinary carboxylic acids was followed by GC/MS. Significant enrichment was found in 3-hydroxypropanoic acid and citric and isocitric acid but not in lactic acid.(ABSTRACT TRUNCATED AT 250 WORDS)

Interpretation of random urinary catecholamines and their metabolites in neuroblastoma

This study reports experience in the estimation of urinary catecholamines (uCATs) and their metabolites in the diagnosis and follow-up of neuroblastoma. Random urine samples were assayed for dopamine, noradrenaline and adrenaline, together with their metabolites 4-hydroxy 3-methoxymandelic acid (HMMA) and homovanillic acid (HVA), using HPLC with electrochemical detection. Twenty of 21 patients had elevation of one or more uCATs metabolites at diagnosis. Patients were monitored serially from diagnosis and, in those patients who had delayed resection of primary tumour (n = 13), particular attention was paid to levels at the pre-surgical evaluation as an indicator of persistence of viable disease at the time of surgery; dopamine proved to be the most accurate indicator of persistent disease at this time. Five of these patients developed recurrent disease, 4 of whom had elevation of two or more uCATs metabolites at the time of relapse. Several conclusions can be drawn from this study: (a) results for HMMA, HVA and dopamine in random urine samples will detect all but the most biochemically immature or inert tumours; (b) dopamine may be the most reliable indicator of persistent disease and (c) noradrenaline and adrenaline measurements were of little benefit. As results are expressed in relation to urinary creatinine, excretion of which may be affected by dietary protein and is therefore not constant, borderline results should be repeated.

Effects of feeding premature infants with Lactobacillus GG on gut fermentation

The study aimed to find out whether gut colonisation of premature babies with a probiotic, Lactobacillus GG, modified enteric carbohydrate fermentation. Twenty preterm infants were randomised to receive Lactobacillus GG 10(8) colony forming units twice a day for two weeks or to a control group. Faecal short chain fatty acids (SCFAs), ethanol, and urinary 2,3-butanediol, were measured in parallel with microbiological studies. Lactobacillus GG colonised nine babies. From 1-28 days of age faecal SCFAs did not differ significantly from controls. Median and ranges were (treated and controls, respectively): acetic acid: 173 (trace-799), 166 (trace-700); propionic acid: 44 (trace-169), 37 (11-229); butyric acid: 31 (5-107), 37 (2-118) mumol/g dry weight. Ethanol was detected in more faecal samples from treated babies (65% v 37%), and at higher concentration (6.3 (trace-40) v 3.3 (0.6-8.8; one 229) mumol/g). 2,3-Butanediol was found in 66% of urine samples from treated babies and 58% from controls. On 83% of these occasions Klebsiella sp, Enterobacter sp, or Serratia sp were cultured from faeces. Lactobacillus GG had no obvious adverse effects on nutritionally important SCFAs. The small increase in ethanol excretion is unlikely to have clinical significance.

Biotinidase activity in patients with liver disease

To investigate whether biotinidase deficiency may occur in liver disease, we determined biotinidase activity, biotin levels, and organic acids in patients with liver disease. Serum biotinidase activity in patients with liver disease (2.63 +/- 1.40 nmol/min/ml) was significantly lower than in the control group (5.43 +/- 1.06 nmol/min/ml). Serum biotinidase activity in decompensated liver cirrhosis (LC) and hepatoma was significantly lower than in acute viral hepatitis (AVH), chronic viral hepatitis (CVH), and compensated LC. The mean serum level of biotin in decompensated LC (1.8 +/- 0.6 microgram/ml) and hepatoma (1.7 +/- 0.8 microgram/ml) was significantly lower than in the control group (2.5 +/- 1.0 microgram/ml), and urinary excretion of biotin was increased in patients with liver disease, particularly in decompensated LC. Biotinidase activity correlated positively with serum biotin level and correlated negatively with urinary biotin level. Moreover, in four of five patients with severe liver disease the excretion of propionate, lactate, and 3-hydroxybutyrate decreased after biotin supplementation. The data for patients with severe liver disease so resembled those for late-onset multiple carboxylase deficiency that biotinidase deficiency is likely in patients with severe liver disease.

Combining two independent indirect methods as a new possibility for screening the illegal use of growth promotants

In this study the possibilities of combined indirect screening methods for the growth promotants clenbuterol and estradiol-17 beta benzoate and the combination of both these agents were investigated. Three groups of 5 male goat kids (two months of age) were treated for 4 weeks; clenbuterol per os, 10 micrograms/day/kg body weight via milkreplacer twice a day; 2 mg estradiol-17 beta benzoate weekly per i.m. injection; combined clenbuterol per os+estradiol-17 beta benzoate per injection. Five animals were not treated and served as controls. Nuclear Magnetic Resonance (NMR) was used as an initial tool to monitor the urine composition. The analysis of NMR spectra showed, that most treated animals had increased L-lactate/creatine ratios (L/C-ratio) in their urine, compared to control animals. For screening, L-lactate/creatine ratios could be determined directly in urine--in a simple, quick and inexpensive manner--by using enzymatic methods and an autoanalyzer. Histologically clenbuterol induced degenerative changes in the urethral and glandular epithelium of the prostate. Changes consisted of vacuolization of the epithelium and necrosis with nuclear pyknosis and fragmentation. Estradiol-17 beta benzoate induced metaplastic changes in the glandular tissue of the goat prostate. In combination with estradiol-17 beta benzoate, characteristics of both agents could be observed. The histological methods and observed effects can be used directly for screening. The combination of independent histological and L/C-ratio methods looks very promising with respect to screening of growth promotants. Since in both cases effects of growth promotants are detected, it may be expected that this approach is not limited to goats or clenbuterol and estradiol alone.

Biochemical diagnosis of phaeochromocytoma: two instructive case reports

The biochemical features of two patients with phaeochromocytomas illustrate the inadvisability of depending on a single group of analytes for the diagnosis. The first case presented as a surgical emergency with retroperitoneal haemorrhage. Biochemical diagnosis was difficult since total 24 hour urinary free catecholamine excretion was within normal limits in two out of three samples, and only marginally raised in the third with an atypical preponderance of adrenaline. Plasma catecholamine concentrations were also normal. But urinary excretion of the catecholamine metabolites, metadrenaline and 4-hydroxy-3-methoxy mandelic acid (HMMA), was consistently raised. In contrast, the second patient presenting with headache and labile hypertension showed normal metabolite excretion in the face of grossly increased free noradrenaline excretion and raised plasma noradrenaline concentrations. It is therefore recommend that, as well as urinary free catecholamines, one group of their main metabolites, the 3-methoxy amines (normetadrenaline and metadrenaline) or HMMA, should routinely be measured whenever a phaeochromocytoma is suspected.

Problems with the biochemical diagnosis in mitochondrial (encephalo-)myopathies

Patients suffering from a mitochondrial (encephalo-)myopathy have a remarkable clinical heterogeneity. A reliable and extensive investigation must be performed in order to obtain a correct diagnosis, but many factors may influence the ultimate results of these investigations leading, under certain circumstances, to an incorrect diagnosis. Patients selection is of crucial importance. Metabolic examination of body fluids, particularly with respect to lactate accumulation, is used as a selection criterion for further examinations. Numerous aspects associated with this metabolic examination have been critically evaluated, including the phenomenon of other causes of lactic acidaemia apart from mitochondrial disorders. Correct performance of in vivo function tests may contribute to a reduction of the number of missed diagnoses. Selection of the controls for biochemical investigations must be accurately be performed to obtain reliable reference values. Knowledge of the age-dependency of the biochemical parameters is necessary for a correct interpretation. It goes without saying that the choice of the tissue for biochemical investigations is of utmost importance. Knowledge of the tissue-specific occurrence of some defects in the mitochondrial respiratory chain is necessary. The biochemical examinations can be performed both in biopsy and autopsy material but only under certain conditions. Diagnostic approach requires application of reliable biochemical methods which are described. One of the most intriguing aspects in the diagnosis of mitochondrial disorders is the significance of a defect in relation to the residual enzyme activity found in the patient. Moreover, attention is paid to relevant items such as the occurrence of multiple and secondary defects.(ABSTRACT TRUNCATED AT 250 WORDS)

Urinary sugar phosphates and related organic acids in fructose-1,6-diphosphatase deficiency

Two sisters with fructose-1,6-diphosphatase deficiency are reported. They presented with ketonuria, elevated plasma transaminase activity and severe metabolic acidosis during hypoglycaemic crises, which resembled Reye syndrome. Intravenous fructose tolerance tests provoked severe hypoglycaemia and metabolic acidosis. Fructose-1,6-diphosphatase activities in both peripheral leukocytes and cultured lymphocytes were below the limit of detection. Urinary organic acid analysis during crises revealed markedly increased excretion of lactate, ketone bodies, glycerol and glycerol-3-phosphate. We newly identified other glycolytic intermediates, glyceraldehyde, 3-phosphoglycerate and fructose-1,6-diphosphate, in the urine during hypoglycaemic attacks or after fructose tolerance tests. Identification of such compounds may be useful in the early diagnosis of this disease.

Neuroblastoma: a 32-year population-based study--implications for screening

This paper describes a retrospective population-based study of neuroblastoma in the West Midlands Health Authority Region--childhood population 1.12 million (OPCS, census 1981)--in which 239 cases were diagnosed between 1st January 1957 and 31st December 1988. The age standardised rate of tumour incidence has remained constant at 7.2 cases per million children per year. The median age at diagnosis was 2 years with 18% of children presenting before the age of 6 months. Fifty children (21%) presented before the age of one year, and for this group of children, the prognosis has improved significantly over the 32-year period (10 year survival increasing from 63% in 1957-67 to 87% in 1978-88), whereas for the 189 (79%) children who presented after one year of age, the prognosis has remained very poor during the study period (10 year survival 1957-67 = 9.5%, 1978-88 = 8.5%). This study supports the need for a prospective study of mass screening at several intervals rather than only at 6 months of age.

Case reports of successful pregnancy in women with maple syrup urine disease and propionic acidemia

We report on 2 women with organic acidemias, one with classical maple syrup urine disease and another with mild propionic acidemia in which protein restricted diets and carnitine supplementation were successfully employed to manage pregnancies. Healthy infants were delivered without maternal metabolic decompensation.

Reference values for urinary HMMA, HVA, noradrenaline, adrenaline, and dopamine excretion in children using random urine samples and HPLC with electrochemical detection

Random urine samples were collected from 305 children aged from birth to 14 years and the values of hydroxymethoxymandelic acid, homovanillic acid, noradrenaline, adrenaline, and dopamine were measured by high-performance liquid chromatography with electrochemical detection. The results were reported relative to the urinary creatinine concentration and the values declined progressively with increasing age for each analyte with the exception of adrenaline. The results for each age group were not normally distributed and all values except outliers were retained in determining the upper reference limits.